Heroes or cowards: healthcare workers' autonomy right versus patient care duties during the COVID-19 pandemic.

Introduction

Since the advent of COVID-19 spread, humankind has become helpless and hopeless in the face of this tragic pandemic that has claimed the lives of numerous people worldwide. Moreover, no one still knows when and how this crisis will end (1, 2). Healthcare Workers (HCW), referred to by social media and governments as health advocates, have been rescuing and protecting many lives during this pandemic. Because HCWs and medical staff, like other members of human society, are entitled to human rights including the right to health, many ethical controversies and dilemmas arose about the HCWs’ role as heroes or cowards in this crisis (3). Such controversies need to be appropriately addressed as this pandemic will not be the last health disaster to face.

The Burden of COVID-19 on HCWs

During the COVID-19 pandemic, HCWs have been experiencing an overwhelming physical and mental pressure and exposed to a high risk of infection and death due to direct and indirect contact with the hospitalized patients. World countries have reported numerous mortalities among their healthcare and medical staff that providing care to the infected patients (4). Major causes of the high infection rate among HCWs are as follows (5): (i) limited supplies of Personal Protection Equipment (PPE), (ii) low awareness about using protection at the beginning of the pandemic, (iii) long-time exposure to the infected cases in emergency and other wards,

and (iv) insufficient training in infection prevention and control protocols. HCWs experience a heavy mental burden because they face stress and burnout in caring for patients (6). Common psychiatric consequences of this mental burden on HCWs are psychological distress, anxiety, depression, fear, Post Traumatic Stress Disorder (PTSD), and stigmatization (7). Fear and avoidance of HCWs lead to significant stigmatization to them, resulting in social isolation and further physical and emotional solitude (7). Such HCWs’ efforts and pressures either have not been acknowledged or have been underestimated because healthcare systems have currently focused on coping with the pandemic as the main target.

During the COVID-19 pandemic, social media, mass media, and governments have called medical staff health advocates and heroes. However, the refusal of various groups of HCWs to provide care in threatening situations, such as an epidemic of highly infectious disease, caused them to be called cowards by others, including colleagues or the general public, since society expected them to make sacrifices to save human lives (8). The controversy over these two conflicting attitudes stems from a fundamental debate about the duty of care or treatment versus the right to refuse to provide care, rooted in HCWs’ eligibility for human rights as others. This controversy led to major moral distress in HCWs which adversely affected the quality of care provided to patients (9). In addition, HCWs’ heroic narratives and calling them brave soldiers in fighting against COVID-19 can have a serious psychological impact on them. These narratives and labels obscure the real situation of HCWs and lead to ignorance of the pressure on them, and hence mislead the public about their needs, rights and duties in caring for the COVID-19 patients (10). This article focused on HCWs’ autonomy, as one of their human rights, to make decisions to fulfill their care-related duties or refuse to provide care (11). Given the high risk of developing COVID-19 symptoms for HCWs, they are concerned about the safety and health of themselves and their families, a concern caused by instinctual feelings that cannot be overlooked. Moreover, if HCWs are in a healthy state, they can provide effective services to patients, and hence the society’s priority should be to ensure HCWs’ health and safety. In addition, HCWs’ right to maintain safety must be respected whenever they feel threatened. HCWs should morally act according to the two major principles of medical ethics: beneficence and non-maleficence (9).

Practical approaches to resolve the aforementioned dilemmas are required for HCWs to provide good quality patient care and have reasonable job satisfaction level. To do so, key steps involve clarifying the duties and rights of HCWs in a health emergency, as well as determining the conditions under which HCWs must perform or should leave their duties during such emergencies (12). The obligatory nature of HCWs’ duties are due to the followings: (i) Their professional responsibilities were defined to care for patients and they were trained to do so; (ii) They have accepted the potential dangers of their profession from the outset of their commitment to the job; (iii) They have to be loyal to their profession, dutiful and vigilant even under unfavorable circumstances and difficult conditions; (iv) The society expects them to make their utmost effort to save patients’ lives, even at the cost of their own health and wellbeing (13). Other factors affecting HCWs’ willingness to stay and perform duties during health disasters such as pandemic are as follows: (i) significant influx of patients seeking care, (ii) professional code of beneficence, a major code of medical ethics, and (iii) duty of accepting risks to help other HCWs and taking on a share of the burden (14). Risk assessment, management and communication are other practical approaches to handle the crisis following the emergence of a highly infectious disease. Successful crisis management at such times includes a series of measures to improve the knowledge of the public and HCWs about the disease, proper evaluation of the risks, and taking effective steps to minimize identified risks. Successful risk management can also support HCWs and reduce the known and unknown fears of facing the disease and infected patients (14, 15). Risk communication, one of the fundamentals of the action plan proposed by the Centers for Disease Control and Prevention (CDC) presented as a brief guide named CERC (CDC’s Crisis and Emergency Risk Communication), has a remarkable role in handling outbreaks. Risk communication includes being the first to share information about the disease, spreading the right information, providing honest and evidence-based information, expressing empathy to both patients and caregivers, promoting actions to stop disease spread, and showing respect to vulnerable populations affected by the disease to promote maximum cooperation (16). Other necessary action plans to mitigate HCWs’ concerns and fears during an outbreak fall into four main categories. (i) Protect HCWs’ safety by providing adequate PPE and giving them a priority for vaccinations and treatments when they become available; (ii) Honest and transparent communication with HCWs about the pandemic’s current situation by providing reliable information enabling them to act more effectively; (iii) Disaster relief programs that enlighten the road of disease management by HCWs; and, (iv) Providing enough knowledge to professionals of disease prevention and control at the workplace to answer HCWs’ concerns promptly (17, 18). Other action plans should target the political authorities and media, which impose additional burdens on HCWs and call them heroes during the pandemic. Such labels and verbal support activities cover shortcomings that political and governmental authorities could not address in an emergency. Calling them heroes dose not empower them in fighting against disease, and realistic approaches as well as actions are required, instead (11). Using proposed approaches, brainstorming as well as reviewing controversies and resolving differences can help improve HCWs’ safety during the pandemic and encourage them to perform their duties willingly and resiliently.

Both medical ethics and medical professionalism have been challenged by the COVID-19 pandemic. Professions related to medical and healthcare involve a social obligation or commitment to humanity. The purpose of this profession is to provide advice and services without certain expectations (e.g., financial compensation, personal benefits), which makes this profession different from other occupations that provide specific services in exchange for living expenses (19). COVID-19 has raised many challenges to altruism, a core idea in medical practice and professionalism defined as giving priority to others’ benefits at the cost of losing self-interest, as HCWs may lose their lives in caring for the COVID-19 patients (20). This condition can be regarded as a major role-related conflict of interest that ethically and professionally affects healthcare providers and needs to be investigated and clarified by experts to illuminate the ambiguities for medical staff and HCWs (1).

An established field in bioethics, concerning health emergencies and disasters such as epidemics and pandemics, focuses on the proper allocation of limited resources in times of need. This field aimed to help clinicians and healthcare professionals respond to disasters or emergencies as effectively as possible, and receive special ethical attention in public restrictions, such as lockdown or quarantine, in such emergencies (21). However, in public health emergencies such as the pandemic, ethics of HCWs as well as their safety and autonomy in providing patient care while maintaining safety need further investigations (15). The controversies highlighted in this article were first raised at the time of the outbreak of Severe Acute Respiratory Syndrome (SARS) in China and south-east Asia in the early 2000s (11, 14). A decade later, COVID-19, a more infectious and hostile epidemic affected almost all world nations, leading to the pandemic and Public Health Emergency of International Concern (PHEIC). Healthcare and bioethical professionals, authorities, and policymakers should consider the current situation as a warning regarding the inadequacy of existing ethical guidelines and discuss with all the healthcare stakeholders to provide more practical guidelines for HCWs in the face of public health disasters.

Conclusion

HCWs’ autonomy versus their duty to patient care, or human rights guidelines versus responsibilities, during an infectious disease outbreak is a controversial issue. This systematic review discussed the existing ethical controversy over healthcare professionals’ autonomy and the proposed practical approaches to solve related dilemmas. Moreover, medical and professional ethics professionals need to provide up-to-date policies and research results to offer more practical solutions for health care providers and help health officials and clinicians find the best way to ethical practice.